Healthcare Provider Details

I. General information

NPI: 1861310641
Provider Name (Legal Business Name): JOSE L ROQUE JR. MSW, RCSWI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 LITHIA PINECREST RD
BRANDON FL
33511-5347
US

IV. Provider business mailing address

126 LITHIA PINECREST RD
BRANDON FL
33511-5347
US

V. Phone/Fax

Practice location:
  • Phone: 656-222-0023
  • Fax:
Mailing address:
  • Phone: 656-222-0023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW20990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: